Monday, January 25, 2010

i am honoured to be a finalist in the category best literary medical weblog in the annual medical weblog awards. the competition is pretty fierce so i won't be holding my breath. here's to hoping though.

Friday, January 22, 2010

i hate lawyers. i know that it comes from a few personal experiences that i've had that have forever tainted my view of them and what they do, but that is the fact of it. i hate them more than i even can say. the first time i saw their dark side may be the incident that left the deepest mark on the hate-lawyers part of my psyche.

it was late at night in kalafong. i was halfway through an omentopexy when someone phoned from casualties. the message was confusing.

"the casualty officer says he has a gunshot wound abdomen of a 16 year old girl in casualties. i told him you're busy operating. he says the patient is dying and asks you if he has your permission to open the abdomen there in casualties?" what the hell!!! i quickly put the scenario together in my mind. even a guy with considerable experience is not going to save someone with an impromptu laparotomy in a casualty situation. he obviously had already decided she was as good as dead and thought some sort of heroic-looking attempt at something might at least create the impression he was doing something. i knew what to say.

"no way at all! the guy who thinks he can do something can come and do it here in theater in a controlled environment and not try to look like some f#@king hero in casualties. i'll finish here as soon as possible and join him. get a second theater ready immediately!"

after that the situation became somewhat surreal with the floor nurse running back and forth with messages between me and the casualty officer as i started rushing my operation more and more in order to hopefully join in the fray before it was all too late.

"the casualty officer says he doesn't think he can do a laparotomy. maybe he should just leave her to die?"

"no way!! he was willing to cut her open from stem to stern just moments ago in casualties. tell him he saddled this horse and now he must ride it. tell him to pull his finger out his ass and do the f#@king laparotomy!" the nurse turned to go. "nurse!" she turned back. "try to soften what i say a bit at least." i was afraid i was going to piss the guy off.

"the casualty officer says he will start but he is calling your consultant in to take over." i knew the consultant was an hour away. he would be too late.

"fine! no problem! just get started!" by this time i was rushing my operation so much i realised i was almost doing half a job. i tried to focus so i didn't end up with two bodies and not just one.

"ok, the patient is on the table in the theater next door. the anaesthetist says she is crashing and he wants to know if she is for active resuscitation?" he would only ask if things were desperate.

"of course she is for f#@king resus. she's sixteen! she is just a kid! we don't just turn around and walk away while kids are busy croaking! we must at least try!! to try and to fail is one thing but to not try at all is inexcusable" at this stage i knew i could leave the rest of the omentopexy to my assistant to sort of close things up with hopefully only minimal complications. anyway i could no longer handle being on the sideline with the gunshot case. i ripped off my gloves and gown and went charging through.

the scene in the other theater was one of the tail end of chaos. everyone was standing around doing nothing. on the table lay a young girl completely naked with one anaesthetist still hovering over her with hands in the cprresus position. there was no resus effort anymore. the other anaesthetist was standing to one side removing his gloves. his brow was dotted with tiny pearls of sweat. the sisters were standing around as if frozen in different acts of resuscitation. one was holding a vaculiter (a bag of intravenous fluid) as if to change the fluid bag which had just run dry. one was standing with a syringe, probably full of adrenaline, sort of swinging it idly between her fingers. the student nurse was standing in a corner as white as a sheet, probably scarred for life. it was over.

i looked at the girl. she was of slight build but her abdomen was swollen to bursting point. her face was ghostly pale. on the dome of her distended belly was a small symmetrical hole smack in the middle. there was an almost innocent gentle stream of blood and feces quietly making its way down her skin from this hole onto the theater table below. the resus efforts had stripped her not only of her clothes, but also her humanity and her dignity. and yet even though she was lying there in the mess of blood and saliva and feces she somehow seemed peaceful. i walked up to her and softly closed her eyes. she deserved at least that. that last picture of her really stuck with me and touched a deep chord of my humanity.

some time after that i happened to be visiting an old school friend who had gone on to study law after school. somehow we ended up speaking about his cases. he spontaneously mentioned a case where a 16 year old girl shot herself in the abdomen just next to kalafong. it was strange in that there was a cop in the house at the time and therefore she was transported to the hospital literally moments after the incident. despite this, my friend informed me, she died. the post mortem revealed a gunshot wound to the aorta. i asked him when this incident had happened and thereby confirmed i knew who he was speaking about.

as it turns out the cop had been called to the house because of domestic violence. the husband, my friend's client, had allegedly threatened his wife with a gun. someone, maybe their 16 year old daughter, had called the cops. that's when the incident happened. the cop was in the house downstairs with the parents trying to mediate peace when a shot went off upstairs. the gun had been found by the girl and she obviously decided that it was all too much. her shot was well placed.

my friend then casually told me that in the initial statement to the cops, the father had said he had placed the gun on the table upstairs before coming downstairs to let the cop into the house. apparently from a legal point of view this fact was the crucial one. it had to do with negligence with a weapon resulting in the death of someone. the father would be in some degree of trouble. my friend had advised his client that this fact made the case indefensible. immediately, the client changed his story to state that in fact the mother, his wife whom he had allegedly threatened with the gun, was in fact the one who had left the gun in easy reach of the daughter and not him. on these grounds they were going to defend him although they knew the man was lying. he relayed this story without flinching.

i thought back to that beautiful girl, ophelia-like, peaceful in death. i thought of the contrast of her youth and beauty with the small hole in her abdomen and the rank stench of spilled bodily fluids in that small theater. i thought of the sad resignation on the face of the anaesthetist whose resus effort had been in vain. i thought of how late at night it was and how the emotional strain had drained us all of any energy and left us tired and spent. and then i looked at my friend's face. the lawyer was smiling at me. he was happy to defend a man who was prepared to lie to save his own skin in the wake of the death of his own daughter. he hadn't seen the real human drama and frankly i don't think he cared.

Monday, January 18, 2010

after having spoken about when you seem to know more than your consultant, i was reminded of another incident from my internship year where a colleague of mine taught me that sometimes it is best to do certain things under cover of darkness.

the patient (a sangoma) turned up at the surgery clinic one day. my colleague asked her what the problem was. without uttering a word she lifted up her shirt to expose her breasts. the left one had a massive tumour that had fungated through the skin probably some time ago. there was a large stinking cauliflower-like mass with central ulceration that caused a fist sized cavity right up to the chest wall. the smell was also remarkable. we couldn't help asking why the patient hadn't sought help earlier, especially seeing that she was supposed to be a so called traditional healer. i mean you didn't have to be a rocket scientist to know that that stinking monstrosity growing right through the chest was not supposed to be there. she simply said that it hadn't been painful, but now she had a cough.

my colleague knew what to do. she would refer the patient to the academic center in bloemfontein in the morning, probably for palliative radiotherapy. to make sure everything was up to date, she took a chest x-ray. it was so impressive she showed it to me. the breast cancer had grown right through the chest wall and had infiltrated the lung below. that is what caused the cough. it was a truly amazing case of neglected breast cancer.

then the cuban surgeon strolled in. this was the sort of thing you just didn't see in cuba. their health system is just too good for something like this to slip through. i suspect they don't have the sangoma problem we are burdened with so on the whole there will be less late stage sicknesses presenting. he was clearly astounded. then he said something that confused both my colleague and myself.

"put her on tomorrow morning's list for me to do a debridement." we looked at him in amazement. my colleague whipped out the x-ray, assuming that after seeing it no sane person would want to put a knife to that thing. i mean where would you stop cutting? in the lung? he looked at the x-ray casually but said nothing.

"you still want me to put her on your list tomorrow?" asked my colleague with more than just a hint of sarcasm in her voice.

"yes." we glanced at each other. maybe there was something we were missing. my colleague entered into a lively debate with him about the rationality of what he was demanding. anyway it was not my patient and i had other things to do so i left as the level of their discussion escalated. i did not envy her position in that she was being asked to do something she knew was not a good idea by any stretch of the imagination.

the next morning i ran into my colleague. she had a broad smile on her face and a somewhat mischievous glint in her eye. obviously the resolution of the matter had been to her liking.

"so," i asked, "did he finally see the light and drop his mad idea?"

"no." she said. the smile didn't falter.

"then what happened?"

"well i was on call last night. so as soon as the sun set and our illustrious consultant went home i bundled the patient into an ambulance and sent her off to the academic hospital. when he got to work this morning the patient was gone. there was nothing he could do." the smile took on an almost sinister look. i was impressed.

years later i employed a similar strategy, but maybe that is better left for another post?

Saturday, January 16, 2010

at least in the old days, our medical training was pretty darn good. but as with all things, confidence comes with experience and experience comes with time. being in the bush with cuban seniors often the confidence was more lacking than the knowledge.

it was late at night. the patient was just one more stab wound chest, one of the most common conditions we dealt with. but this one was different. he writhed around and seemed to be gasping for air. i threw in the needed intercostal drain, expecting a sudden improvement. it didn't happen. the lungs were fine, but the patient's neck veins were severely distended. his blood pressure was low and his pulse was fast and thready. his heart sounds sounded muffled and distant. then, if i wasn't already sure about the gravity of the situation, he said those words which strike dread into any doctor who has even a little experience.

"help me doctor, i'm dying!"

i knew what was wrong. he had a pericardial tamponade (the heart had been stabbed and was bleeding into the sack around the heart, slowly crushing its attempts at normal contractions) and without intervention the patient was going to do exactly what he had said he was going to do. i even knew what to do, but had never even seen it being done before. he needed a needle to be stuck into this sack to draw off the blood. this would win time to get him to theater to fix the hole in the heart. it was time to phone my senior.

the cuban surgeon on call sounded sleepy. he listened to my presentation of the patient, but didn't seem to fully appreciate how grave i felt the situation was. so i told him.

"this patient has a tamponade and without intervention soon he will die!""how can you diagnose a tamponade without a chest x-ray? get an x-ray and phone me back!" i was astounded. i knew what i had and didn't need a chest x-ray to help me. in fact i was worried about the delay the getting of said x-ray would cause. nevertheless, he was the consultant and i was merely the intern. i had to obey.

not too much later i phoned the consultant again."i have the x-ray as you requested and it shows a very globular heart." this confirmed the diagnosis. "will you please come out and help?"

finally he arrived. i had been sitting next to the patient the whole time trying to reassure him that everything was going to be just fine even though i was not convinced everything was in fact going to be fine. the consultant looked at the x-ray for some time. he then listened to the ever fainter heart and examined his now engorged neck veins. i was pacing by this time. i just couldn't understand the consultant's tentativeness. after all he was supposed to be a surgeon.

"bring me a needle!" finally!! i presented him with the needle and syringe that i had already gotten ready. he seemed surprised. i wanted to say that i was south african trained, but thought better of it and just smiled. he then started cleaning the chest just next to the sternum. now once again due to my south african training i had expected him to clean the area just below the sternum in the angle between the left ribs and the sternum. where he was cleaning i feared that he may stick the needle straight through the thin sliver of lung that lies over the heart in this position. i mentioned my misgivings and suggested the method we had been taught. glared at me accusingly and drove the needle in through his original site. the syringe quickly filled with blood. the change in the patient was dramatic and instantaneous. i started to breathe easier too.

"wonderful!" i said. "theater is ready. i took the liberty of booking him already.""why?" said the cuban. i was taken off guard. it seemed to me to be self evident. the stab to the heart had to be addressed otherwise the tamponade could recur and then we'd have to operate in the early hours of the morning anyway."ummm...to fix the hole in the heart?" i ventured."no. we have treated him. he is fine now. admit him to the ward!" and with that he walked out.

what could i do? i was an intern. i could not do a thoracotomy on my own. if the surgeon refused to operate the patient was not going to get operated. i hesitantly admitted him to the ward as instructed.

through the night i intermittently stopped by to see how my patient was doing to the irritation of the night staff whose sleep i constantly interrupted. by the next morning the patient was amazingly still alive. sometimes patients are just lucky i suppose.

Friday, January 08, 2010

being south african these days sometimes means we see things in a slightly skewed way. it seems to be the way we have become. i have touched on this before, but there is another story which illustrates the point.

the recent run of hijackings were fresh in all our minds because the perpetrators had shot and killed, execution style, a mother and her three year old child just the previous week. there were reports that one specific gang was working the area and were responsible for most if not all the hijackings and associated killings in the area. so when our patient came in, even before the police told us so, we just assumed he was one of this gang.

the story was the police had intercepted this guy just after he had relieved a car owner of his mode of transport. he was good enough not to kill the victim this time around which was nice. however, not being the law abiding type, he had driven off in haste with the police hot on his tail. according to the police he fired first. whatever the truth was, bullets were moving liberally in both directions between our man and the law as they flew through the streets of pretoria in a westerly direction. unfortunately for the hijacker he had chosen the toll route and was forced to stop at the toll gate just outside kalafong hospital. he jumped out and opened fire on the cops in the now multiple cars pursuing him. they shot back. they hit him four times. they gave me real reason for concern about the aim of our police force. the only wound which was anything more than a flesh wound was the shot to his left brachial artery (the main artery in the upper arm).

ironically, the patient had comitted his initial crime in the drainage area of pretoria academic hospital, a place with a dedicated vascular unit, but had fled into the drainage area of kalafong hospital that had no vascular service at all. i thought this would have been divine justice, but, alas, his proximity to kalafong at the time of the shooting along with the fact that his shooters, the police, immediately transported him to the nearest hospital ensured that he had prompt help. the fact that my friend and colleague on call that night just happened to have a knack with vascular surgery also swung the odds heavily in the favour of our patient. obviously my views about karma were once again confirmed.

and so the next day when we went on rounds the patient was actually doing quite well. he sat up, looking at us as we stood around his bed to discuss his case. his ordeal had done nothing to his smooth mouth and arrogant attitude. in fact, the only sign of his life saving and arm saving operation in the dead of night was the large fasciotomy running along the length of his forearm (essentially a long open wound along the length of his forearm) and the police escort that lazily sat next to his bed.

my friend, the guy who had essentially saved the patient's life and limb, felt the pulse. i thought he would be proud of its strong beat, but there was something else on his mind.

"the police of today don't know how to shoot!" he said. "they shoot kak!" i think this was aimed at whoever wanted to listen. but the next statement was specifically for the patient. he turned to the patient and continued.

"i, however don't shoot that badly. if you come near me or mine, be warned i'll kill you on the spot. my bullet won't just take out some artery. i'll hit you in your heart and you won't see another sunrise. just to let you know." i'm not even sure the patient knew this was the very person who had given up his night's rest to meticulously repair the artery and thereby save the patient's life. i don't think he was the type to care, actually.

two days later, before the fasciotomy could be closed, the patient escaped from the hospital while his police escort lay lazily around. i reflected that all we could really hope for was that his open wounds would turn septic and he would succumb to systemic sepsis. we all knew he was too bad a man for that to happen.

Friday, January 01, 2010

many years ago a friend of mine told me a story which i thought quite touching. it seems like a nice way to kick off the year.

one of my seniors in surgery had a dog that meant a lot to him. he lavished it with love and attention and they were inseparable. he had trained the dog to obey him implicitly. in fact it was so well trained that he would often go for walks with it without a leash. one word from him and the dog would stick to his leg like glue. this was one of those walks.

my friend and his best friend were out walking. it was a quiet day so my friend would send his dog out far ahead. he would then shout the command for it to stop and wait. he would then either leisurely catch up to the dog or give the command for it to return to him. then he sent the dog ahead again, but this time didn't notice the dog would be crossing a street. as the dog was half way across the street my friend saw a truck barreling down at full speed towards the dog. he panicked and, instead of shouting for the dog to return, just screamed the dog's name. the dog stopped dead in his tracks, right in the middle of the street...and was run down.

soon the dog was at the vet. most of the injuries were to the leg, but they were bad. so bad in fact that the vet said only an amputation would suffice. she then added that this breed of dog didn't do too well with an amputation because they needed to run around a lot or they became depressed and lost the will to live. she suggested euthanasia. my friend was devastated, but he agreed that the dog would not do well without a leg. he consented.

just before the injection he went through to his faithful old friend to say goodbye, but when the dog looked up at him and, despite the pain wagged its tail and smiled he knew he could not just stand by. he asked the vet if she could anaesthetise the dog. he would do the rest. he then drove to the hospital where he was training, walked into theater and pretty much stole all the orthopaedic plates and screws he thought he would need. not too long afterwards he was drilling and hammering and doing the things bone doctors do, but on his dog. somehow he got it all together, although he had to sacrifice the articulation of the wrist. a stiff wrist was better than no wrist.

and so the dog recovered and went on to have a full and happy dog life.

p.s i'm not condoning the stealing of all the hardware but when i confronted him about that he pointed out that the hospital had refused to pay him overtime well in excess of the value of the items stolen and, he said, he could therefore live with it.

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.